Texas A&M University-Corpus Christi
Academic Misconduct Incident Form
Part I: General Information (note: please complete an incident report form for each alleged violator.)
Instructor Name: Click here to enter text.
Department: Click here to enter text.
Date: Click here to enter a date.
Instructor Phone Number: Click here to enter text.
Instructor Email Address: Click here to enter text.
Course/Section: Click here to enter text.
Date of Alleged Violation: Click here to enter a date.
Student Name: Click here to enter text.
Student ID #: Click here to enter text.
Student Phone Number: Click here to enter text.
Student Email Address: Click here to enter text.
Part II: Charge
I am charging the above named student with a violation of academic misconduct as specified below. Check all that
apply. Please refer to the procedures for the definitions of academic misconduct (University Rules and Procedures
13.02.99.C3.01). A copy of the procedures along with the Student Code of Conduct can be found online at
judicialaffairs.tamucc.edu
☐Cheating
☐Plagiarism
☐Multiple Submissions
☐Collusion
☐Fabrication, Falsification or Misrepresentation
☐Other: Click here to enter text.
Please describe the alleged violation and all parties involved, to include all witnesses (attach additional sheets as
needed.) Since the burden of proof is on the instructor, please attach to this form all documentation of the alleged
violation, the course syllabus and specific instructions for the assignment.
Click here to enter text.
Part III: Sanctions
Please mark the academic sanctions that have been taken against the student. Check all that apply.
☐Written Reprimand
☐Grade of “F” for Work in Question
☐Re-do Work in Question
☐Grade of “F” for Course in Question
☐Submit Additional Work
☐Other:Click here to enter text.
☐Lowering of Grade of Work in Question
Formal Disciplinary Recommendation of Faculty Member (optional):
☐ I recommend no formal disciplinary action unless the student has a history of academic dishonesty.
☐ Based on the severity of this individual incident I recommend formal disciplinary action. I understand that the
student may be placed on disciplinary probation, suspended or dismissed from the University based on this incident
alone and/or the student’s history of academic misconduct.
Part IV: Rights and Process:
Please review the rights listed below and the faculty member, along with the student should initial each line indicating
understanding. Any questions regarding the statements or the process should be addressed through the Office of the
Associate Dean of Students.
Student Initial Faculty Initial
___________ ___________ 1. The academic misconduct process indicates that instructors are to present students
with this completed form, along with any evidence associated with the alleged charges.
___________ ___________ 2. This form, along with the syllabus for the course, the instructions for the assignment,
the work completed and any evidence associated with this case are to be submitted to the Office of the Associate Dean
of Students along with the Chair of the Department for proper record keeping purposes.
___________ ___________ 3. This process is not considered complete until communication from the Office of the
Associate Dean of Students is received indicating that no further action is to be taken. If this process is not complete
prior to the date for final grades to be submitted , then a grade of “I” is to be issued until the matter is resolved.
___________ ___________ 4. Students may not be incentivized to respond to this form in any particular manner.
Part V: Resolution
The student should carefully read each resolution and initial the appropriate space indicating which resolution they
are choosing:
____Acceptance of Responsibility and Sanction – this resolution indicates an acceptance of responsibility for the alleged
violation listed above and an acceptance of the sanction as assigned by the instructor. If a previous history of academic
misconduct exists, the Office of Judicial Affairs may request an Academic Integrity Hearing Panel be convened to hear
the case and additional sanctions may still be assigned.
____Acceptance of Responsibility, Denial of Sanction – this resolution indicates an acceptance of responsibility for the
alleged violation listed above, but a denial of the sanction as assigned by the instructor. The Office of judicial affairs will
refer this matter to the Department Chair for mediation. If no solution is reached, an Academic Integrity Hearing Panel
will convene to determine appropriate sanctioning.
____Denial of Responsibility – this resolution indicates a denial of responsibly for the alleged violation listed above. An
Academic Integrity Hearing Panel will convene to make a finding regarding responsibility and sanctions.
I affirm by my signature that I understand my rights and options as described in the Procedures for Academic Misconduct
Cases. In addition, both the instructor and the student understand that there will be a delay of any academic penalty
until the conclusion of the Academic Integrity process and that any history of academic misconduct may be considered
during the process.
Student Signature:___________________________________________________________Date:___________________
☐Student failed to appear
☐Student refused to sign document
Faculty/Instructor Signature:___________________________________________________Date:___________________
Please return this form and all relevant materials including evidence showing the violation, assignment instructions
and the course syllabus to the Office of the Associate Dean of Students via the online reporting system:
incidentreportform.tamucc.edu and provide a copy to your department chair. If you have any questions, please do
not hesitate to contact the Student Conduct Officer at 361-825-6219.
Adapted from Illinois State University & Northern Illinois University with permission. Updated 8/2015 – AW/KS